Status asthmaticus treatment drugs. It has a half-life of 4–6 h and rapid onset of action. An antacid (Maalox) is prescribed for a client with peptic ulcer disease. Symptoms of moderate persistent asthma can include: chest tightness or pain Nov 28, 2005 · Part 10. ) A. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. Hyperresonance E. Mar 1, 2003 · Treatment with aminophylline has been shown to improve oxygenation and reduce the incidence of intubation in children with severe status asthmaticus. Status asthmaticus - Download as a PDF or view online for free. Health & Medicine Entertainment & Humor. FOAM and web resources. No interventions or discontinuations of magnesium sulfate due to adverse events in the study. Sep 30, 2009 · The treatment of patients in severe status asthmaticus must be prompt and efficient. Without oxygen, many organs begin to malfunction. If an asthma attack is life-threatening, a machine may be used to help you breathe and get extra oxygen. Then be sure to follow your plan. Inhaled beta-agonists, systemic corticosteroids, and oxygen remain the drugs of choice in SA. Despite a better understanding of the disease process and its management, status asthmaticus continues to be a life-threatening event. The nurse should be prepared for the next intervention if the patient does not respond to treatment. Mar 2, 2013 · Abstract and Figures. (See also Asthma and Drug Treatment of Asthma. Albuterol, a short-acting β 2 agonist, is the most widely used bronchodilator for the treatment of acute asthma. k. The first line of treatment of status asthmaticus starts with beta-antagonists, corticosteroids, and theophylline. B) Gentamicin (Garamycin) IM. 5: Near-Fatal Asthma. These symptoms may be caused by exercise or exposure to odors, allergens, or respiratory tract infections. sucralfate, A client asks "Why can't I take Prednisone every day for my Apr 2, 2024 · Medicines: Medicines may be used to decrease inflammation, open airways, and make it easier to breathe. 1 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and May 31, 2017 · Abstract. Assess the client's respiratory status. Call emergency services for the client. Benefits of SCIT are small improvements in symptoms and QOL, reduction in long-term medications. If appropriate, reduce corticosteroid dosage gradually and supervise such reduction Oct 12, 2018 · Without a doubt, bronchodilators represent the single most important treatment for a cat having a life-threating asthma attack (status asthmaticus). g. an obstructive pattern of FEV1/FVC < 70% is consistent with diagnosis. a. Thomas Petty: " the best treatment of status asthmaticus is to treat it three days before it occurs. since it is defined by being relatively refractory to high dose inhaled therapy. Apr 2, 2024 · Cough-variant asthma is a type of asthma that causes a dry cough that keeps coming back. A severe asthma attack (called status asthmaticus) that does not respond to fast-acting medications can lead to respiratory failure. For this review, status asthmaticus is defined as Study with Quizlet and memorize flashcards containing terms like A client with a history of duodenal ulcer is admitted to the hospital with status asthmaticus. Intravenous magnesium sulfate is a useful adjunct if therapy with β-agonists and anti-cholinergics are not effective initially. Asthma accounts for >2 million emergency department visits and 5000 to 6000 deaths annually in the United States, many occurring in the prehospital setting. Select drug class All drug classes Vasopressors (6) Methylxanthines (3) Decongestants (1) Adrenergic bronchodilators (22) Glucocorticoids (20) Tocolytic agents (1) Catecholamines (6) Jun 18, 2019 · Status asthmaticus is a severe and life-threatening asthma state. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based Nov 9, 2022 · In the treatment of status asthmaticus, intubation (insertion of a breathing tube into the airway) is normally avoided if at all possible. 4% of status asthmaticus cases occurred Dec 29, 2021 · pulmonary function tests. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. High-risk predictors: Signs of severity: See Table 205-2 for drug dosages. increase of ≥ 12% from baseline and ≥ 200 mL. Status asthmaticus can vary from a mild form to a severe form with bronchospasm, airway inflammation, and mucus plugging that can cause difficulty breathing, carbon dioxide retention, hypoxemia, and respiratory failure. C) Albuterol (Proventil) puffs. Oct 13, 2016 · Status asthmaticus was defined as an acute asthma exacerbation with persistent symptoms unresponsive to initial bronchodilator therapy. (2,3) RELATED: People with severe asthma are also much more likely to experience Oct 13, 2016 · Status asthmaticus was defined as an acute asthma exacerbation with persistent symptoms unresponsive to initial bronchodilator therapy. lisinopril b. Cough-variant asthma is treated the same way as typical asthma. Other medications that can used to treat status asthmaticus are anticholinergics Asthma is the most common chronic disease of childhood. Constantly monitor the patient for the first 12 to 24 hours, or until status asthmaticus is under control. Short-term medicines relieve your symptoms quickly. Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators. They have also been used to stop shivering during therapeutic hypothermia following cardiac arrest, in elevated intracranial pressure and in status asthmaticus. Get vaccinated for influenza and pneumonia. A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. ACEP Now — Rapid Sequence Intubation Pharmacology (2010) The pharmacologic treatment of status asthmati-cus includes high-dose inhaled bronchodilators and the early administration of oral or IV corticoste-roids. ) > 80% of baseline), the acute exacerbation may be managed in the Jun 4, 2016 · Status asthmaticus, also known as acute severe asthma, is a condition of progressively worsening bronchospasm and respiratory dysfunction due to asthma, which is unresponsive to standard conventional therapy and may progress to respiratory failure and the need for mechanical ventilation ( 3 ). It is often fatal if not recognized and treat … Nov 3, 2020 · Butler J, Jackson R. prednisone e. Do not abruptly discontinue systemic or inhaled corticosteroid therapy upon initiation of benralizumab therapy. Dec 9, 2021 · Refractory status asthmaticus is the cause of rare cases of in-hospital death due to acute bronchial asthma. With all types of asthma, the airways become inflamed and narrow, making it harder to Apr 6, 2024 · With your doctor and health care team, write a detailed plan for taking medications and managing an asthma attack. 01) (Table 4). There are several second-line treatments available; however, few comparative studies have Sep 30, 2020 · Dexamethasone is as effective as methylprednisolone and should be given as soon as possible. Choose the correct three of the following options. , propofol). C) An 18-month-old child with seasonal allergic rhinitis. (2) Problematic hypotension due to conventional sedatives (e. Jul 1, 1997 · Status asthmaticus occurs when the disease process progresses with or without treatment. 04 mg/kg of body weight) was given subcutaneously in multiple doses. Albuterol in combination with ipratropium bromide in the emergency department …. inhaled corticosteroids c. initial emergency treatment of a client in status asthmaticus includes which medications? a. It is generally considered as an acute exacerbation of bronchial asthma, characterized by severe obstruction and not relieved by usual treatment. Prognosis is good with treatment. In which order should the nurse administer the prescribed medications? (Arrange from first to last. In status asthmaticus, the lungs are no longer able to provide the body with adequate oxygen or to remove carbon dioxide adequately. An increase of glycolysis pathway leading to pyruvate escalation is the mechanism of hyperlactatemia in β2-adrenergic agonist drug. The nurse knows that the purpose of this medication is to. 1. The most severe cases unresponsive to first, second and next line treatment may be fatal despite aggressive organ support with invasive ventilation and extracorporeal membrane oxygenation. Patients may have been admitted to the PICU or general wards. Heliox-driven albuterol nebulization after 1 hour of continuous nebulization and steroids. Mechanical ventilation. Management of patients with status asthmaticus, especially when requiring invasive mechanical ventilation, is requisite knowledge for the intensivist. Upon admission to the emergency center, an adult client with acute status asthmaticus is prescribed this series of medications. 5 mmol/min MgSO4 intravenously, airway Jun 18, 2023 · Not indicated for treatment of acute asthma symptoms or exacerbations, acute bronchospasm, or status asthmaticus. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client diagnosed with status asthmaticus who is currently not receiving any medical treatment. It usually presents in childhood and is associated with other features of atopy, such as eczema and hayfever. They were consequently treated with enoximone, a selective phosphodiesterase III inhibitor, in their refractory phase. 5 per 1,000 deliveries where women with asthma received IV labetalol were complicated by status asthmaticus versus 1. Apr 1, 2024 · Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. In a severe asthma exacerbation, these symptoms fail to respond to rescue inhalers. Corticosteroids. B) A 2-year-old child with moderate persistent asthma. Medical emergency when bronchospasm is refractory to bronchodilator and steroids in the ED. In which order should the nurse administer the The effect of administration of terbutaline on the pulmonary and cardiovascular systems was studied in ten children with status asthmaticus. 5-mg ipratropium improved pulmonary function and reduced admissions. It is a medical emergency that requires immediate recognition and treatment. 1,4,5 The selective b2-agonists are considered to be the bronchodilators of choice for patients with acute bronchospasm. MAX 8,000 mg for 4 hours, monitor for cardiopulmonary complications. The cause of exercise-induced obstruction is not understood. 01 to 0. , A physician orders a beta2 adrenergic Whereas the GINA guidelines are an ongoing series of revisions on a broad range of asthma topics, the 2020 Focused Updates targeted six key areas of asthma care for which there was strong interest Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. 2. In practice, the role of the physician is to prevent this from happening through patient compliance with controller medications (eg, steroid Jun 17, 2020 · Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators. Increase the oxygen flow to 3 L/min. thmaticus. The choice to intubate a patient with status asthmaticus is made clinically. A nurse is developing a plan of care for a client who has COPD. A significant decrease in respiratory rate and in arterial blood pressure, with no significant change in cardiac rate, was seen only after the first dose of . Taking control of your treatment can make you feel more in control of your life. 5 or above. Treatment includes. The Global Initiative for Asthma guidelines refers to a severe asthma exacerbation describing a patient who talks in words, leans forward, is agitated, uses accessory respiratory muscles, has a respiratory rate > 30/min, heart rate > 120/min, O 2 saturation on air < 90% and PEF ≤ 50% of their best or predicted value []. Hypoxia, dehydration, acidosis, and hypokalaemia render the severe acute asthmatic Acute severe asthma describes serious asthmatic attacks, which remain a major treatment challenge and a significant source of morbidity in adults. Severe shortness of breath, rapid breathing, or difficulty breathing. IV salbutamol improves lung function tests and gas exchange but its toxicity increases as the concentration increases . No side-effects were observed. treatment of contributory factors, or that worsens when high dose treatment is decreased. STATUS asthmaticus refers to a life-threatening asthmatic episode that is initially unresponsive to vigorous therapy with epinephrine, aminophylline, aerosolized bronchodilators, and hydration. naproxen c. Which of the following medications should the nurse question? Select all that apply. Jan 28, 2019 · People with moderate persistent asthma experience symptoms typically every day, or at least most days in the week. It is the extreme form of an asthma exacerbation that can result in hypoxemia, hypercarbia, and secondary respiratory failure. IV beta-adrenergic agents d. In stepwise management Sep 12, 2023 · Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required. ) A) Prednisone (Deltasone) orally. The main focus of nursing management is to actively assess the airway and the patient’s response to treatment. Initiation of asthma attack triggered by an allergen or other irritants. There are however case reports, in paediatric and adult patients, suggesting its efficacy (2,3,5) in mechanically ventilated patients with status asthmaticus unresponsive to conventional treatment. the bronchial tubes. Aug 23, 2021 · Status asthmaticus is a life-threatening complication of asthma wherein airway obstruction is unresponsive to the usual therapies described above. The therapy for status asthmaticus consists of intravenously administered aminophylline, corticosteroids, nebulized β-adrenergic agents, and oxygen. Oct 5, 2023 · Ipratropium is a drug also used to open airways that is inhaled with an inhaler or a nebulizer. Medicines may be inhaled, taken as a pill, or injected. Due to alterations in airway physiology, standard ventilation strategies cannot be employed. Reynel Dan. Symptoms and signs include dyspnea, chest tightness, cough, and wheezing. See the stepwise approach to asthma medications in Table 1, below. Have the client cough and expectorate secretions. It is severe, intense, prolonged airway narrowing that is resistant to treatment. 1,4 When inhaled in high doses, these agents are rapidly effective and Jan 12, 2021 · Background Salbutamol-induced lactic acidosis is a rare presentation that could manifest in specific clinical context as acute asthmatic attack treatment. The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. Prompt assessment and aggressive treatment are critical. Topics: agonists, anticholinergic agents, bronchodilator agents, glucocorticoids, status asthmaticus, asthma, oxygen, helium The bronchodilating effect of magnesium sulfate (MgSO4) was studied in two patients with status asthmaticus, who were intubated and mechanically ventilated by a respirator. Terbutaline (0. This is made worse by the fact that the excellent outpatient management of asthma has filtered out the mild and Comparing risk for status asthmaticus among patients receiving labetalol and carboprost, 6. Asthma comprises a range of diseases and has a variety of heterogeneous phenotypes. The 72-hour time frame was chosen, as it exceeds the mean LOS in pediatric status asthmaticus of 2. Select one or more: a. Sep 7, 2017 · Patients with severe asthma make up only 3% 1 to 10% 2 of the population of adults with asthma, but their care is estimated to account for more than 60% of the costs associated with asthma, which Mar 4, 2020 · SCIT. However, how severe the obstruction, what modalities of therapy are included and over what time frame, are usually not specified. However, with the advent of biologic Aug 8, 2023 · Asthma is a common disease and has a range of severity, from a very mild, occasional wheeze to an acute, life-threatening airway closure. Aug 7, 2023 · Silent Asthma Symptoms. Assess the clients respiratory status. A significant decrease in respintory rate and in arterial blood pressure, with no significant change in cardiac High-dose, prolonged magnesium may expedite discharge from the ED in non-infectious asthma in pediatric study [17] 50 mg/kg/hr for 4 hours. Which risk factor should the nurse consider for this client? (Select all that apply. " (7) Still, there will be asthmatics with life-threatening attacks that require careful assessment and aggressive management. Status asthmaticus has not been well defined. Anxiety D. B. , A client asks "Why can't I take prednisone every day for my arthritis like my grandmother did?" Jul 26, 2022 · The symptoms of severe asthma include trouble breathing, wheezing, a persistent cough, and chest tightness or pain. A patient with life-threatening asthma and status asthmaticus was treated with sevoflurane general anesthesia. Acute severe asthma, also known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and corticosteroids. Asthma is a chronic lung disease that affects the airways, a. In a study 107 of severely ill asthmatics with peak flows less than 200 L/min on arrival to the emergency department, 0. Chest tightness. Status asthmaticus can lead to an accumulation of air in that pleural cavity, which is called a pneumothorax, and cardiac and respiratory arrest. Care of patients with life-threatening asthma in the intensive care unit (ICU) is challenging. Lignocaine as a pretreatment to rapid sequence intubation in patients with status asthmaticus. First-line treatment entails continuous treatment of nebulized short-acting b-receptor agonists and intra-venous (IV) steroid administration. Apr 12, 2023 · There is insufficient high-level evidence to know exactly where this should fit in the treatment rubric. Hyporeflexia, The nurse is preparing to teach a client who is Jun 1, 2018 · Inhaled β 2 agonists are classified based on the duration of their effect: short-acting β 2 agonists and long-acting β 2 agonists. Other medicines may be needed if your regular medicines are not able to Upon admission to the emergency center, an adult client with acute status asthmaticus is prescribed this series of medications. Jul 25, 2023 · Nursing Management. The progression of symptoms can be either rapid or more indolent, but either course can result in respiratory failure. Next: Beta2-Agonists. The most severe form of asthma is called status asthmaticus. 24 Unfortunately, the therapeutic level of Study with Quizlet and memorize flashcards containing terms like A client with a history of duodenal ulcer is admitted to the hospital with status asthmaticus. Nov 2, 2022 · Respiratory failure occurs when insufficient oxygen passes from the lungs into the bloodstream, or when the lungs can no longer remove carbon dioxide (a waste product) from the blood. 3), Description (11)]. furosemide d. Doctors also call it acute severe asthma. 1 Classified as an allergic disease, feline asthma is the result of a type-1 hypersensitivity to specific aeroallergens. Feline asthma is a lower airway disease that affects 1% to 5% of cats, 1 most commonly young to middle-aged cats. 1 Although median age on diagnosis has been reported to be 4 to 5 years, most cats with asthma experience clinical signs earlier in life. At present, therefore, ‘severe asthma’ is a retrospective label. Omalizumab, a humanized recombinant monoclonal anti-IgE antibody, is an approved add-on biological This report describes the treatment of eight patients with status asthmaticus, six of whom were already maximally treated. These drugs also may be appropriate for long-term management of cats with intermittent episodes of respiratory distress not well controlled by gluco­corticoids alone. maintain a gastric pH of 3. Cause is usually by upper respiratory infection, allergen exposure or decrease in anti-inflammatory meds. PMC1726553. if normal in a well patient but high clinical suspicion, induce with a methacholine challenge. The diagnosis is based on history, physical examination, and pulmonary function tests. Inflammatory immune response in the airway. Patients with mild or moderate exacerbations in the office should be treated with repeated doses of four to 10 puffs of a SABA every 20 minutes for one hour. C. Jun 16, 2015 · Acute status asthmaticus is a fragile thing which, most ICU specialists would agree, is a good reason to get out of bed and drive to the hospital. 3. Optimize control, avoid in severe asthma, administer in clinical setting. IV salbutamol should be limited to use in the pediatric ICU, where continuous cardiac monitors Jun 17, 2020 · Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators. D) None of the above; montelukast is not approved for use in children. 1 Management of asthma attacks includes administration of inhaled β 2 adrenergic agonists, inhaled anticholinergic May 17, 2023 · The intensity of treatment depends on the severity of symptoms. Best evidence topic report. The addition of ketamine to the standard treatment regimen of severe asthma has shown to improve outcome and Aug 1, 2001 · The concomitant use of ipratropium in the emergency department for treatment of status asthmaticus remains controversial. Hypercapnia C. A dry cough may be your only symptom, or you may also have chest tightness. What is the pathophysiology of status ashmaticus? 1. Alkalosis B. Status asthmaticus signs and symptoms. Emerg Med J. The recognized Most deaths from acute asthma occur outside hospital, but the at-risk patient may be recognised on the basis of prior ICU admission and asthma medication history. For most patients with mild to moderate asthma exacerbation, EMS treatment with nebulized albuterol is all that Dec 12, 2012 · British guidelines on the management of asthma do not support the routine use of rhDNase or mucolytics for the treatment of severe acute asthma (4). Bronchodilatation in these patients was immediate. 2005 Oct;22(10):732. Corticosteroids are given as a pill or shot to treat inflammation. Mar 21, 2012 · Status asthmaticus. Treatment involves controlling triggering factors and drug therapy, most commonly with inhaled beta-2 agonists and inhaled corticosteroids. Follow the links to read common uses, side effects, dosage details and read user reviews for the Status asthmaticus (SA) is a severe and life-threatening asthma exacerbation that requires aggressive treatment. Status Asthmaticus. Airway resistance was continuously monitored by the respiration-controlled interruption technique. Status asthmaticus must be distinguished from other causes of wheezing such as pulmonary edema, pulmonary emboli, upper airway obstruction, or an acute Study with Quizlet and memorize flashcards containing terms like As status asthmaticus worsens, the nurse would expect which acid-base imbalance?, After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Asthma is an ongoing condition that needs regular monitoring and treatment. May improve co-morbid allergic conditions. Enoximone appears to be a valuable addition to the treatment of status Mar 15, 2019 · This treatment should be limited for patients with status asthmaticus who fail to respond to a continuous nebulized beta2-agonist. Importance of shared decision-making. One possible explanation for the progressive deterioration is that some patients underestimate the severity of the airflow obstruction. It is sometimes called ‘severe refractory asthma’ 1. Status asthmaticus is a common cause of morbidity and mortality. It places the patient in danger of developing respiratory failure, a condition known as status asthmaticus. Status asthmaticus can vary from a mild form to a severe form with bronchospasm, airway inflammation, and mucus plugging that can cause difficulty breathing, carbon dioxide retention, hypoxemia, and Jun 17, 2020 · Practice Essentials. Definition of Acute Severe Asthma. The medications listed below are related to or used in the treatment of this condition. Status asthmaticus is considered a medical emergency. Long-term medicines are used to prevent future asthma attacks. oral corticosteroids The goal of asthma exacerbation treatment is to relieve symptoms and return patients to their best lung function. Rationale: Status asthmaticus is potentially a life-threatening respiratory event, so albuterol, a beta2 adrenergic agonist and short acting bronchodilator, should be administered by inhalation first to provide rapid and deep topical penetration to relieve bronchospasms, dilate the bronchioles, and increase oxygenation. Case presentation A 40-year-old man who had poor-controlled asthma, presented with progressive dyspnea with Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis. Situations where this should be considered are the following: (1) Refractory status asthmaticus with inability to ventilate safely. 4 days and is a surrogate of more severe disease. Asthma attacks account for 1. 11. Aug 22, 2019 · 2. Overall, 71. inhaled beta-adrenergic agents b. Risk of systemic reactions. The etfect of administration of terbutaline on the pul monary and cardiovascular systems was studied in ten children with status . After administration of 0. • Severe hypersensitivity to milk proteins or any ingredients of PULMICORT FLEXHALER [see Warnings and Precautions (5. Mar 21, 2012 •. Asthma is caused by multiple genes , some having protective effect, with each gene having its own tendency to be influenced by the environment although a As in the words of Dr. This condition is a medical emergency that can cause death without treatment. 8 million emergency department (ED) visits each year in the US and for 10 deaths daily. The goal of office and emergency room management of acute asthma is reversal of airway obstruction by the administration of inhaled β-adrenergic medications. Inhaled bronchodilators (beta-2 agonists and anticholinergics) Usually systemic corticosteroids. Patients who fail to improve significantly in the emergency department should be admitted to an HDU or ICU for observation, monitoring, and treatment. Status asthmaticus may be precipitated by a variety of causes, including exposure to allergen, air pollutants, respiratory tract infections, emotional stress, weather, noncompliance with medications, and aspirin or other nonsteroidal anti-inflammatory drugs. 2 This immune response Mar 10, 2023 · Blockade drugs have been used in the ICU mainly for intubation but has been maintained for mechanical ventilation (in up to 90% of the patients) as shown in a review 30 years ago. Bronchospasms can be exacerbated by intubation, making breathing more difficult and inducing laryngospasms. If rapid-acting beta2-agonists are used more than 2 days a week for symptom relief (not including use of rapid-acting beta2-agonists for prevention of exercise induce symptoms), stepping up treatment may be considered. In the Sep 22, 2020 · Common symptoms of status asthmaticus can include: Bluish skin, lips or nails. Difficulty speaking due to breathlessness. if consistent with obstructive lung disease, reverse with a beta-agonist. Reduction of Corticosteroid Dosage. These people tend to die rather readily, typically of cardiac arrest due to dynamic hyperinflation and the resulting loss of preload. Sweating. Acute asthmatic attacks account for nearly 1 million emergency room visits Nov 1, 2019 · Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy. The use of volatile inhaled anesthetics is infrequently reported as adjunctive therapy to conventional treatment of this condition. Consensus guidelines. 1 of 16. 7 per 1,000 deliveries with other antihypertensive medications (p<0. 219 likes • 83,863 views. Below is a list of common medications used to treat or reduce the symptoms of status asthmaticus. 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